Options on aneurysms

For some patients with brain aneurysms, a minimally invasive option combines 3-D imaging, special tools and techniques so patients can forego open-skull surgical procedures.

As Stephanie Weiss was coming to grips with the news she had two large and three small aneurysms in her brain, the independent travel consultant was told there was no minimally invasive way to treat at least one of the defects: a wide-neck aneurysm. She would have to undergo open-brain surgery.

That was before she met Michael J. Alexander, MD, a neurosurgeon specializing in neurovascular and skull base surgery. He also is a neurointerventionalist: an expert in minimally invasive procedures performed with instruments guided by 3-D imaging through blood vessels to the brain or spinal cord.

Alexander explained that the Food and Drug Administration recently had approved a new device that made it possible to close even a wide-neck aneurysm like hers – which was pressing against the optic nerve – without the higher risks, pain and longer recovery of major surgery.

Aneurysms, weak areas of arteries that balloon out, can have catastrophic consequences if they burst. Very small aneurysms may be monitored over time; for most defects that pose a threat, two main treatment options exist: In an open-brain operation, surgeons may place a metal clip at the neck of the aneurysm to close it. Alternatively, surgeons or neurointerventionalists may take the minimally invasive route to fill the aneurysm with platinum coils.

But large and wide-neck aneurysms present a special challenge because the base of the “balloon” is very broad.

“The coils would just pop back out of the aneurysm and potentially block the artery. In recent years, we’ve used stents – called vascular remodeling devices – to keep coils in the aneurysm and out of the artery. The new device virtually eliminates the need for coiling in some cases and may be an option in instances where coiling has failed,” said Alexander, professor and clinical chief of the Department of Neurosurgery. He is director of the Neurovascular Center, which has become one of the largest referral centers on the West Coast since Alexander joined Cedars-Sinai in 2007.

Alexander, who treats patients by both conventional open-brain surgery and minimally invasive, endovascular techniques, also directs the West Coast’s only endovascular neurosurgery fellowship program accredited by the Society of Neurological Surgeons Committee on Accreditation of Subspecialty Training.

He often serves as a proctor, instructing other doctors in the use of newly introduced products and procedures, and in July, he will begin a one-year term as president of the Society of NeuroInterventional Surgery, a national organization of 650 – neurosurgeons, radiologists and neurologists – who treat brain aneurysms, strokes, carotid artery blockages, other brain artery disorders and spinal abnormalities through minimally invasive procedures.

Weiss said Alexander’s dual-training expertise – knowing he could perform open-brain surgery but wasn’t limited to it – was reassuring. She eagerly chose the neurointerventional route, and in a procedure that took less than two hours, Alexander sealed off the wide-neck aneurysm with the new device and stabilized the other large aneurysm with conventional coiling.

“I’ve gone to a dentist and it’s been more complicated,” said Weiss, who was able to make phone calls two hours after the procedure, spent one night in the hospital and cleaned her house three days later.